Health Management Information System Data Research Articles

Decreasing incidence of admission neonatal hypothermia in Gandhi Memorial Hospital, Addis Ababa, Ethiopia: quality improvement project

BackgroundWHO reported that neonatal hypothermia accounts for about 27% of newborn deaths worldwide. It is a serious concern in Ethiopia and other parts of sub-Saharan Africa; it poses a serious...

A time series analysis of disruptions to maternal and child health care in northern Togo during the COVID-19 pandemic in the context of an integrated primary care program

There are significant concerns that COVID-19-related disruptions in routine health care will reverse the gains made over the past 2 decades in reducing maternal and under-5 mortality in low- and middle-income countries. The objective of this study was to examine the extent of disruptions in community-based maternal and child health services and explore community perceptions and experiences with health care use in the year following the start of the COVID-19 pandemic in one district in northern Togo, West Africa. This study included analysis of multiple types of data including: (1) routine health management information system data from 18 public sector health centers, (2) programmatic data collected through an integrated health center- and community-based primary care program at 5 health centers, and (3) semi-structured interviews with health center managers, community health workers (CHWs), and community members at those 5 health centers. We found only short-term declines in service utilization coinciding with the COVID-19 pandemic and no decline in the delivery of community-based care by CHWs. Qualitative data were consistent with the quantitative results, reporting sustained use of health-care services. Multilevel factors related to the continued provision of care during the COVID-19 pandemic included regular and clear communication from CHWs as trusted community sources, risk minimization at the health-center level, continued provision of community-based care by CHWs, and collaboration between community leaders and health-care workers to limit COVID-19 transmission. Findings demonstrate resiliency of an integrated primary care system when equipped with an adequately trained, supervised, and supplied health workforce, implementation of infection prevention and control measures, communication by trusted community sources, and adaptations to health-care delivery that enable the continued provision of care.

The Health Management Information System and HIV and AIDS monitoring: Insights from Ethiopia

Background: A well-performing health information system (HIS) provides timely, complete, accurate and easily retrievable data. However, HIS in low- and middle-income countries (LMICs), including Ethiopia, is highly complex and influenced by pressures from donors, politics and technical factors. Hence, these countries experience persistent challenges in producing quality data and difficulties using health management information system (HMIS) data from their HISs.Objectives: This study aimed to evaluate how HMIS was perceived and utilised in HIV and AIDS monitoring in Ethiopia, and views regarding the influence of determinants on the use of HMIS.Method: A qualitative evaluative case study using focus group discussions with data producers and users was conducted in selected health facility in Addis Ababa. A purposive critical case sampling was used to recruit participants.Results: Key findings revealed that HIV and AIDS-specific indicators, information and communication technology (ICT) and other related resources were critical barriers to the successful use of the HMIS. Participants believed these technical issues impacted the quality of data adversely and, subsequently, the conversion of that data to information and using it to monitor the HIV and AIDS programme’s performance.Conclusion: Technical factors affected all strategic decisions taken by the organisation. The health facilities did not process information as expected. However, staff performed the HMIS tasks with the tools available as they tried to make sense of data.Contribution: This study contributed to the body of knowledge by identifying the technical factors on data quality and use of HMIS for HIV and AIDS monitoring.

Trends and Inequalities in Maternal and Newborn Health Services for Unplanned Settlements of Lusaka City, Zambia.

Living conditions and other factors in urban unplanned settlements present unique challenges for improving maternal and newborn health (MNH), yet MNH inequalities associated with such challenges are not well understood. This study examined trends and inequalities in coverage of MNH services in the last 20 years in unplanned and planned settlements of Lusaka City, Zambia. Geospatial information was used to map Lusaka's settlements and health facilities. Zambia Demographic Health Surveys (ZDHS 2001, 2007, 2013/2014, and 2018) were used to compare antenatal care (ANC), institutional delivery, and Cesarean section (C-section) coverage, and neonatal mortality rates between the poorer 60% and richer 40% households. Health Management Information System (HMIS) data from 2018 to 2021 were used to compute service volumes and coverage rates for ANC1 and ANC4, and institutional delivery and C-sections by facility level and type in planned and unplanned settlements. Although the correlation is not exact, our data analysis showed close alignment; and thus, we opted to use the 60% poorer and 40% richer groups as a proxy for households in unplanned versus planned settlements. Unplanned settlements were serviced by primary centers or first-level hospitals. ZDHS findings show that by 2018, at least one ANC visit and institutional delivery became nearly universal throughout Lusaka, but early and four or more ANC visits, C-sections, and neonatal mortality rates remained worse among poorer than richer women in ZDHS. In HMIS, ANC and institutional delivery volumes were highest in public facilities, especially in unplanned settlements. The volume of C-sections was much greater within facilities in planned than unplanned settlements. Our study exposed persistent gaps in timing and use of ANC and emergency obstetric care between unplanned and planned communities. Closing such gaps requires strengthening outreach early and consistently in pregnancy and increasing emergency obstetric care capacities and referrals to improve access to important MNH services for women and newborns in Lusaka's unplanned settlements.

Evaluation of Emergency Contraceptive Pill Use with Health Management Information Systems Data in Pakistan.

According to the WHO, all clients should have access to a range of contraceptive methods, including at least one short-term, one long-term, one permanent, and one emergency method of contraception. While there are data on the contraceptive method mix available for many low- and middle-income countries, there are limited data on emergency contraception (EC). This is likely due to some surveys not routinely collecting this information, how survey questions are asked, dual method use, and/or low levels of reported use of EC pill (ECP). Even with low reported use in surveys, contraceptive social marketing statistics from DKT International. show a trend in recent years of increasing product sales of ECPs. To understand a more complete scope of ECP use, we use Pakistan as a case study and analyze Pakistan's Demographic Health Survey (DHS) surveys and Pakistan's Contraceptives Logistics Management Systems. Based on commodities dispensed data for ECPs in 2021, about 0.4 percent of all married women in Pakistan use ECPs. While there is currently a small proportion of women, it is growing and the use of ECPs is not zero as indicated by the DHS. Therefore, where available, countries should review their health management information systems data alongside survey data for ECP use.

Malaria trends in districts that were targeted and not-targeted for seasonal malaria chemoprevention in children under 5 years of age in Guinea, 2014–2021

BackgroundSeasonal malaria chemoprevention (SMC) is a main intervention to prevent and reduce childhood malaria. Since 2015, Guinea has implemented SMC targeting children aged 3–59 months (CU5) in districts with high...

Assessing the impact of COVID-19 pandemic on maternal healthcare usage: evidence from routine health data in Kenya and Ethiopia

ObjectivesLockdowns and fear of COVID-19 may have reduced access to antenatal care (ANC) and skilled birth attendance (SBA) in sub-Saharan Africa, which could undermine progress towards maternal and child survival...

Impact of Urban Slum Residence on Coverage of Maternal, Neonatal, and Child Health Service Indicators in the Greater Accra Region of Ghana: an Ecological Time-Series Analysis, 2018-2021.

Among other focus areas, the global Sustainable Development Goals (SDGs) 3 and 11 seek to advance progress toward universal coverage of maternal, neonatal, and child health (MNCH) services and access to safe and affordable housing and basic services by 2030. Governments and development agencies have historically neglected the health and well-being associated with living in urban slums across major capital cities in sub-Saharan Africa since health policies and programs have tended to focus on people living in rural communities. This study assessed the trends and compared inequities in MNCH service utilization between slum and non-slum districts in the Greater Accra region of Ghana. It analyzed information from 29 districts using monthly time-series Health Management Information System (HMIS) data on MNCH service utilization between January 2018 and December 2021. Multivariable quantile regression models with robust standard errors were used to quantify the impact of urban slum residence on MNCH service utilization. We assessed the inequality of MNCH coverage indicators between slum and non-slum districts using the Gini index with bootstrapped standard errors and the generalized Lorenz curve. The results indicate that rates of vaccination coverage and antenatal care (ANC) attendance have declined significantly in slum districts compared to those in non-slum districts. However, skilled birth delivery and postnatal care (PNC) were found to be higher in urban slum areas compared to those in non-urban slum areas. To help achieve the SDGs' targets, it is important for the government of Ghana and other relevant stakeholders to prioritize the implementation of effective policies, programs, and interventions that will improve access to and utilization of ANC and immunization services among urban slum dwellers.

Improving Malaria Case Management and Referral Relationships at the Primary Care Level in Ghana: Evaluation of a Quality Assurance Internship.

In Ghana, Community-based Health Planning and Services (CHPS) compounds managed by trained nurses and midwives called community health officers (CHOs) play a major role in malaria service delivery. With heavy administrative burdens and minimal training in providing patient care, particularly for febrile illnesses, including malaria, CHOs struggle to comply with the World Health Organization's test, treat, and track initiative guidelines and appropriate referral practices. A clinical training and mentorship program was implemented for CHOs to prevent and manage uncomplicated malaria and offer appropriate pre-referral treatment and referrals to district hospitals. Medical officers, pharmacists, midwives, health information officers, and medical laboratory scientists at 52 district referral hospitals were trained as mentors; CHOs from 520 poorly performing CHPS compounds underwent a 5-day internship at their assigned district referral hospital to improve knowledge and clinical skills for malaria case management. Three months later, mentors conducted post-training mentoring visits to assess knowledge and skill retention and provide ongoing on-the-job guidance. Significant percentage-point increases were observed immediately post-internship for history taking (+12.0, 95% confidence interval [CI]=8.3, 15.1; P<.001); fever assessment (+24.9, 95% CI=20.9, 29.3; P<.001); severe malaria assessment and referral (+32.0, 95% CI=28.2, 35.8; P<.001); and knowledge assessment (+15.8, 95% CI=10.0, 21.3; P<.001). Three months later, a third assessment revealed these gains were largely maintained. Analysis of national health management information system data showed statistically significant improvements in testing, treatment, and referral indicators at intervention CHPS compounds after the intervention that were not observed in comparison CHPS compounds. This training and mentorship approach offers a replicable model to build primary care provider competencies in malaria prevention and management and demonstrates how developing relationships between primary care and first-level referral facilities benefits both providers and clients. More methodologically rigorous studies are needed to measure the impact of this approach.

Title: Identifying barriers to the production and use of routine health information in Western Province, Zambia.

Recent decades of improvements to routine health information systems (RHISs) in low and middle-income countries (LMICs) have increased the volume of health data collected. However, countries continue to face several challenges with quality production and use of information for decision-making at sub-national levels, limiting the value of health information for policy, planning, and research. Improving the quality of data production and information use is thus a priority in many LMICs to improve decision-making and health outcomes. This qualitative study identified the challenges of producing and using routine health information in Western Province, Zambia. We analyzed interview responses 37 health and social sector professionals at the national, provincial, district, and facility levels to understand the barriers to using data from the Zambian health management information system (HMIS). Respondents raised several challenges that we categorized into four themes: governance and health system organization; geographic barriers; technical and procedural barriers; and challenges with human resource capacity and staff training. Staff at the facility and district levels were arguably the most impacted by these barriers as they are responsible for much of the labour to collect and report routine data. However, facility and district staff had the least authority and ability to mitigate the barriers to data production and information use. Expectations for information use should therefore be clearly outlined for each level of the health system. Further research is needed to understand to what extent the available HMIS data address the needs and purposes of the staff at facilities and districts.

An assessment of storage practices of essential medicines in primary health centers of Gadag taluk, Karnataka

Background: The efficacy and safety of medications may be impacted by the potency loss that occurs during storage. Pharmaceuticals need to be stored under controlled conditions and transportation situations to make sure its quality isn't harmed. A crucial component of the overall drug control system is storage. Wherever pharmaceuticals and supplies are kept on the property, sufficient environmental control must be maintained, including the right temperature, light, and humidity levels, as well as sanitary, ventilation, and segregation requirements. Methods: A cross sectional study was done to assess the Storage conditions of medicines in pharmacies of primary health centers of Gadag Taluk. Storage facilities was assessed using observational checklist. Sampling design was universal sample all 15 primary health centers (PHCs) as per health management information system (HMIS) data was assessed for Storage conditions of essential medicine in primary health centre. Results: Results indicate that storage conditions for essential medicines are: 80% of pharmacies have a dedicated warehouse or storage space for drugs; 100% have a method to control temperature; 93.33% have cold storage facilities; 100% use racks; only 33.3% have drugs arranged with identification labels; manufacturing dates and expiration dates are clearly visible; and medicines are stored in a systemic way. Conclusions: In summary, the primary health centre's pharmacies are generally storing medications correctly, but there is room for improvement. Labelling drugs, managing expired drugs, and training staff can help improve storage and drug supply. These measures can ensure better medication storage conditions.

Why district assemblies disburse resources to district health systems for service delivery at district level in the context of decentralization: a comparative study of two districts in the Volta Region of Ghana.

To explore why the District Assembly disburses financial and other resources to the District Health System. Multiple case study with a single unit of analysis (holistic) using quantitative and qualitative methods of data collection involving a desk review, analysis of routine health management information system data and key informant interviews. Two districts in the Volta Region of Ghana. Twelve key officials of each district assembly and the district health system (24 total) who had worked in the district at least a year or more. None. Both District Assemblies had moderate decision space which was influenced by their capacity, power and contextual factors like politics, economics, legal and situational factors. Disbursement of financial and other resources to the District Health Systems was influenced by financial capacity, use of power by stakeholders, context and the decision space of the District Assembly. Political actors appeared to have more power in resource disbursement decision making than community members and technocrats in a context of resource constraints and inadequate funding. The funding available was used predominantly for capital investments, mainly construction of Community Based Health Planning and Services (CHPS) compounds. It is important to make policies that will regulate the relative power among the political appointees like the District Chief Executives (DCEs), public and civil servants in decentralized departments and agencies and Community members to make resource disbursement more sensitive to communities and decentralized departments.

Determining the Level of Health Management Information System Data Use in Southern Region of Lesotho

Health management information system (HMIS) has been implemented in many countries to promote evidence-based decision making. The aim of this study was to generate information that will help the Ministry of Health (MOH) to improve the use of HMIS data at district level in southern region, Lesotho. This was a descriptive cross-sectional study which employed explanatory mixed methods approach. Quantitative data were collected through records reviews while qualitative data were collected through interviews and records reviews. The findings have shown that DHMTs and district hospitals are using HMIS data quite satisfactorily. Also, data demand by managers and possession of HMIS skills influences the use of data. In conclusion, the main enablers to a satisfactory level of HMIS data use in the southern region were ability of managers to demand data from their subordinates and improved data quality because of intensive interventions aimed at strengthening Lesotho’s HMIS by external donors.

An Assessment of the Availability of Essential Medicines in Gadag Taluk, Karnataka: A Study of Primary Health Centers.

Background Essential medicines are those that meet the priority healthcare needs of most of the population and are included in the 2030 Agenda for Sustainable Development. The national list of essential medicines should be tailored to the specific needs of each nation and should always be accessible at reasonable prices and with guaranteed quality. Methods A cross-sectional study was done to assess the availability of essential medicines in primary health centers (PHCs) in Gadag Taluk. The data for the assessment of availability was collected using a checklist, which was prepared after reviewing the Karnataka list of essential medicines, surgical items, and miscellaneous items from 2021 to 2022 for PHCs. The sampling design was a universal sample of all 15 PHCs, as per health management information system data, to assess the availability of essential medicine in PHCs. Results Results indicate that theavailability of essential medicines in 15 PHCs in Gadag Taluk is 74.20%. The availability of anti-allergic drugs and drugs used in anaphylaxis was around 88%, whereas the availability of antidiabetic drugs and non-steroidal anti-inflammatory drugs was 86.88% and 86.66%, respectively. All other categories of drugs are available above 50%, except ophthalmic and ear, nose, and throat drugs. Conclusion The public sector should be strengthened by making sure that patients have access to free essential medicines and that essential medications are always available. This would help patients spend less money out of their own pockets and move India closer to achieving universal healthcare.

Data for local decision-making, not a mere reporting requirement: development of an index to measure facility-level use of HMIS data

Background Well-functioning health management information systems (HMIS) enable decision-making at all health system levels. This study develops an index to measure the use of HMIS data at the facility level. Methods We used two rounds of cross-sectional data collected from 305 health facilities in Ethiopia in 2019 (pre-COVID-19) and 2020 (post-COVID-19). We constructed a summative, 10-item index using exploratory factor analysis and 2019 index development data; and used Cronbach’s alpha to assess reliability. To examine content validity, we mapped items against a previously published conceptual framework and consulted Ethiopian experts. We then employed one-way ANOVA and t-tests comparing the mean index scores overall and by key facility characteristics between 2019 and 2020. Results The 10-item index loaded on one factor (Cronbach’s alpha=0.74), and the index scores did not differ significantly by facility characteristics in 2019. The mean index score increased from 7.2 in 2019 to 7.9 in 2020 (P&lt;0.01). During this period, more facilities received feedback on HMIS reports from facility leadership (19.3% difference); received actionable recommendations on performance targets and resource allocation (7.5% and 12.3% difference, respectively); and reviewed maternal deaths (15.1% difference); conversely, the proportion of facilities that held participatory performance review meetings monthly or more often decreased by 13.8% (all P &lt;0.05). Conclusions We propose a facility-level HMIS data use index and document an upward trend in HMIS data use in Ethiopia immediately after the COVID-19 pandemic was declared. Future research should further evaluate and refine the proposed index to support the measurement of HMIS data quality and utilization in Ethiopia and like settings.

Uptake of reproductive, maternal and child health services during the first year of the COVID-19 pandemic in Uganda: A mixed methods study.

Use of reproductive health (RH), maternal, newborn and child health (MNCH) services in Uganda is suboptimal. Reasons for this are complex; however, service-delivery factors such as availability, quality, staffing, and supplies, contribute substantially to low uptake. The COVID-19 pandemic threatened to exacerbate existing challenges to delivery and use of high-quality RH and MNCH services. We conducted a mixed methods study, combining secondary analysis of routine electronic health management information system (eHMIS) data with exploratory key informant interviews (KII) to examine changes in health service uptake over the course of the pandemic and to understand service delivery adaptations implemented in response. We analyzed eHMIS data for four services (family planning, facility-based deliveries, antenatal visits, and immunization for children by one year), comparing them across four time periods: pre-COVID-19, partial lockdown, total lockdown and post lockdown. Additionally, KIIs were used to document adaptations made for continuity of health services. Use of services declined substantially during total lockdown; however, rebounded quickly to earlier observed levels, during the post lockdown for all four services, especially for immunization for children by one year. KIIs identified several health services delivery adaptations. At the community level, these included: community outreaches, training some mothers as community liaisons to encourage others to seek health services, and support from local leaders to create call centers to facilitate clients transport during travel restrictions. Health facilities creatively used space to accommodate social distancing and shifted providers' roles. District leadership reassigned health workers to facilities closest to their homes, provided vehicle passes to staff, and ambulances to transport pregnant women in critical need. WhatsApp groups facilitated communication at district level and enabled redistribution of supplies. Ministry of Health produced critical guidelines for continuity of health services. Implementing partners provided and redistributed commodities and personal protective equipment, and provided technical support, training and transport.

Impact of COVID-19 on utilization of maternal and child health services in India: Health management information system data analysis

Background/ObjectivesStudies globally have documented the impact of COVID 19 on maternal and newborn health services. This study assesses the impact of COVID-19 on essential maternal and child health (MCH) services in India based on the national Health Management Information System (HMIS). MethodsPresent retrospective study used secondary data analysis upon the routinely collected data accessed from Health Management Information System. Microdata on maternal and newborn indicators was extracted for all states between April and June during 2019, 2020 and 2021. Relative change for each indicator were taken into consideration for the year 2020 and 2021; with respect to the outcomes in 2019. ResultsCompared to 2019, antenatal care registrations saw a decline in all states for both periods in 2020 and 2021 except for Sikkim, Telangana, Maharashtra and Andhra Pradesh. Similarly, the relative changes in 2019 pertaining to the proportion of pregnant women provided with emergency obstetric care for pregnancy complications registered a decline in all states except for Himachal Pradesh, Telangana and Arunachal Pradesh. There was a decreasing trend noted in institutional deliveries in 2020 and 2021 among all major states. However, an increasing trend was seen in the number of immunization sessions held among all major states. ConclusionThe study demonstrates a disruption in service delivery during the lockdown period in the first wave and the peak of the second wave. Further qualitative studies need to be undertaken to generate evidence for maintaining continuum of care during a pandemic situation.

The impact of telemedicine services on primary health care - before and after analysis- Jharkhand digital dispensary model

Background: The service utilization at primary health cares (PHCs) by the rural population is challenging considering the lack of service availability and health care practitioners. Telemedicine and digitization of services have high potential to address the service provision gaps. Government of Jharkhand and Apollo tele health services-initiated PPP project to provide digital healthcare (digital dispensary) services at 100 rural PHCs in the state of Jharkhand. Methods: The research study seeks to explore before and after impact of telemedicine services at the government run PHCs at Jharkhand. This retrospective analysis of health management information system (HMIS) and Jharkhand digital dispensary (JHDD) project data was performed for 19 PHCs out of 100 where JHDD project has been initiated. A pre-post study design was used to understand the impact of JHDD project implementation and uptake of outpatient department (OPD) utilization. The 19 centers were randomly selected using selective sampling, considering the data availability and travelling restrictions. Primary baseline data was analyzed in the excel sheet and secondary data- was entered, verified, and analyzed with statistical package for the social sciences (SPSS) version 25. Results: Patients have to travel up to 75 kms to visit a doctor and avail health services. Medical officer was adequate, but not available for eight hours and every day. JHDD project data have highlighted the prevalence of NCDs in rural areas with significant increase in the diagnosis of diabetes and hypertension. The availability of general physician and specialist doctors virtually, with laboratory tests and medicines were the enabling factors in addressing the NCDs for the rural areas. Conclusions: Telemedicine is strong enabler in addressing NCDs in remotest inaccessible areas. The study has pointed out the importance of available remote workforce, basic infrastructure and technology can strengthen the healthcare system by reaching the unreached.

Impacts of COVID-19 on reproductive health service provision, access, and utilization in Ethiopia: Results from a qualitative study with service users, providers, and stakeholders.

Ethiopia has made significant improvements to sexual and reproductive health (SRH) in recent decades, yet the COVID-19 pandemic brought new challenges to SRH service delivery. In the early months of the pandemic, health facility and health management information system data showed reductions in SRH service utilization, however more evidence is needed on ongoing SRH impacts to inform policy and program decision-making. Our study aimed to assess the impacts of COVID-19 on SRH service utilization and access from the perspective of providers, clients, and stakeholders in Addis Ababa and Amhara Regional State. We collected data from May through July 2021 via six focus group discussions with health service providers, 50 in-depth interviews with SRH service clients and 15 key informant interviews with policy and programmatic stakeholders. All audio recordings were transcribed and translated from Amharic into English. Data were coded and analyzed for content and themes using Excel and NVivo 10. We found that COVID-19 and associated public health mitigation measures had consequences on SRH prioritization, funding, and service delivery. Efforts to halt the spread of COVID-19, such as gathering and transportation restrictions, also reduced access to SRH services. Fear of infection, costly and inaccessible transportation, commodity stockouts, and limited service availability all impeded access to and use of SRH services. For some women, this meant losing timely access to contraception and subsequently facing unwanted pregnancies. Providers experienced increased workloads, anxiety, and stigma as possible sources of infection. Our findings offer useful learnings for program and policy stakeholders aiming to meet SRH needs during the pandemic, and during times of crisis more broadly.

Increasing Contraceptive Use Through Free Family Planning Special Days in Poor Urban Areas in Francophone West Africa.

In francophone West Africa (FWA), contraceptive uptake remains limited, often due to geographic, economic, and social barriers. With technical support from The Challenge Initiative (TCI), municipalities and health systems implemented Family Planning Special Days (FPSDs) to improve family planning (FP) uptake and reduce high unmet need. The FPSD intervention consisted of organizing free FP services on a monthly or quarterly basis over 2 to 5 consecutive days within health facilities or sites close to the population. These events helped to educate, inform, and mobilize the community around FP and improve geographic and financial access to FP services. We describe the process of implementing FPSDs in FWA countries and analyze the results. We used several techniques and data sources in our descriptive analysis, including document review of activity reports, analysis of health management information system data, and retrospective data collection on the profile of FPSD users and implementation costs. Between July 2020 and June 2021, municipalities and health systems collaborated to hold 1,046 FPSDs in 452 health facilities in 10 FWA cities. This collaboration was made possible through the establishment of city-level management and coordination units composed of municipal, health system, and TCI focal points. In the 10 FWA cities, 181,792 people were made aware of the FPSDs and 71,669 contraceptive users were served. The overall cost of organizing the FPSDs was about 145382501 Central African CFA francs (US$252839), 35% of which came from the municipalities' local financial contribution. Results from our analysis showed that, with appropriate financial support from municipalities, the health system could offer high-quality free FP services. Nonetheless, there are still challenges to the sustainability of conducting FPSDs, including the availability of contraceptive products and continued financing of the strategy during system shocks such as the COVID-19 pandemic.